There’s a provocative editorial in a recent New England Journal of Medicine about the explosive rise in high-tech medical imaging. Everyone knows doctors order a lot of CT scans, MRI scans, and ultrasound studies, and that the number of these has been steadily increasing. And the cost is enormous. From the article: ” . . . these costs were the fastest-growing physician-directed expenditures in the Medicare program, far outstripping general medical inflation.”
To be fair, rising use of new medical technology is expected because, well, it’s new. What is unclear is that how much of this increased use has led to improved health to justify the cost. Clearly much of it doesn’t, and unnecessary scans, particularly CT scans, lead to risk with no benefit.
The practice of “defensive medicine,” of doctors ordering tests out of a fear of being sued for missing rare conditions, is often given as a cause for overuse of scans. There is some truth to that: the article cites a Massachusetts study showing that 28% of scans are done for that reason. Lawsuits over failing to diagnose things are common; lawsuits about overuse of tests are vanishingly rare.
Physician conflict-of-interest also plays a part. Through a loophole in Medicare regulations, physicians are allowed to refer patients for scans from which the physician benefits financially. That is wrong and needs to be fixed.
But there are deeper reasons. The root cause may well be “the style and content of clinical education and their impact on medical practice.” In other words, how doctors are trained. We use scans unthinkingly, and, unthinkingly, can cause harm. Again from the editorial: “The greatest risk that patients face with unnecessary imaging is the needless exposure to downstream testing and inappropriate treatment related to misdiagnosis and the overdiagnosis of common but unimportant findings.” I’ve seen that happen more than a few times.
By now everybody knows that the Senate passed a healthcare reform bill last week. The House passed such a bill last month. The bills differ in important respects, and of course it is still unclear if the two bills will be reconciled in conference committee to produce a bill that both houses will pass. If a final conference bill does pass, it will have ground-breaking effects on medical care. What might change in the PICU?
My first-blush answer is that it will have important effects for me, my colleagues, and our patients, but not so much as it might for other aspects of medical practice. Why do I say that? First, look at where our current healthcare dollars come from (source is here):
Private insurance: 35%
Medicaid and SCHIP: 15%
Other public funds: 12%
Other private funds: 7%
These figures are for the entire system. As I’ve written before, the PICU is different — very different. Around half of children in the PICU already are covered by Medicaid, the joint federal/state program for children of poor families. This startling statistic is a reflection of the fact that poor children are far more likely than are affluent children to end up in the PICU.
But even though half the children in America’s PICUs are on Medicaid, half are not, and the healthcare reform bill can have a major impact on them, especially those from families who are presently uninsured. A PICU bill can bankrupt those families. This bill will reduce the number of times that will happen, and I think that is a good thing.
Opponents of the current proposals in Congress for reforming healthcare have asserted that nearly all physicians are in opposition to these measures. I’ve even read claims that physicians will leave practice in droves if any of these bills pass, leaving America short of doctors. The highly respected Robert Wood Johnson Foundation recently surveyed physicians to see how we actually felt about reform. You can read the summary of their findings here. The bottom line — a large majority of physicians favor reform.
The survey found that 63% of physicians supported a public option — a system in which there was a government-funded alternative to private insurance. More radical than that, 10% supported a straight-up single payer system, such as Canada has. In sum, this is three-quarters of America’s doctors. In addition, a majority (58%) supported lowering Medicare eligibility to include 55-year-olds.
The survey does not address reasons doctors think this way. I think a majority of them, like me, realize our current non-system is unsustainable financially. I also think it is immoral socially, but I may be in the minority on that one.